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After taking a 10-day course of an antibiotic that was
ineffective, a frail, elderly client with chronic obstructive
pulmonary disease (COPD) is admitted for pneumonia.
The client has a long history of smoking and still smokes a
pack of cigarettes a day. Which finding should the
registered nurse (RN) report to the healthcare provider?
A. Barrel chest with increased chest diameter
B. Crackles and pulse oximetry level of 88%
C. Low hemoglobin and hematocrit levels
D. Arterial blood gases indicating respiratory acidosis -
Answer-B. Crackles and pulse oximetry level of 88%
Rationale: With pneumonia, crackles in the lungs and low
O2 saturation (B) can impact adequate oxygenation, which
should be reported to the HCP. (A) occurs due to chronic
hyperinflation of the lungs and is common in clients with
COPD. Anemia (C) is frequently identified in clients with
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COPD, and respiratory acidosis (D) due to CO2 retention
contributes to a lower blood pH.
An older female client recently moved to an assisted living
facility. The family explains to the registered nurse (RN)
that the client is unmanageable and always confused,
disoriented and depressed. The client asks the RN
repeatedly, "Where am I?". How should the RN respond?
A. Explain that she is in a new home called an assisted
living community
B. Question the client about her perception of where she
might be now.
C. Distract the client with a scenario that she is on an
outing with her family.
D. Reassure the client not to worry because she will meet
new friends. - Answer-A. Explain that she is in a new
home called an assisted living community.
Rationale: Reality re-orientation (A) is the best response
for a client who is confused because the response is
consistent and true. (B, C, and D) do not provide the client
with feedback that is reality based.
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A new resident in an assisted living facility is an older
client who is experiencing short-term memory loss and
confusion. Which activity should the registered nurse (RN)
schedule the client to do during the day?
A. Arts and crafts
B. Current events discussion group
C. Group sing-along
D. Daily exercise group - Answer-D. Daily exercise group
Rationale: A daily exercise group (D) allows the client to
mirror the leader and minimizes the client's stress to
remember. (A), (C), and a current events discussion group
(B) are thought-provoking activities that require attention
to detail and short-term memory to participate in the group
activity which may be stressful and frustrating to the
resident who has difficulty remembering sequence of the
details.
The hospice nurse is completing a focused assessment of
an older female client with end stage Alzheimer's disease,
who recently fractured her hip. What technique should the
registered nurse (RN) use to determine the client's pain?
A. Use the FACE pain scale
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B. Ask the client to rate pain on a scale of 1 to 10
C. Observe for facial grimacing
D. Review documentation of recent eating habits -
Answer-C. Observe for facial grimacing
Rationale: Observing for facial grimacing (C) is the best
method for evaluating pain for a client who cannot
communicate due to Alzheimer disease. (A) and (B) may
not be understood by a client with end-stage Alzheimer's
disease. (D) is not a helpful tool for pain assessment.
An older male client arrives at the clinic for an annual
physical examination. While the nurse assesses the client,
the client states that he is having intimacy problems with
his wife. Which information should the nurse provide to
elicit more information from the client?
A. Query client to clarify the client's idea of an intimacy
problem.
B. Discuss benign prostatic hypertrophy (BPH) and
ejaculation.
C. Explore the frequency that he experiences erectile
dysfunction (ED)